A neuroma is an entrapment of a small nerve in the foot, causing chronic swelling inside the nerve that may result in permanent nerve damage. The most common site for a neuroma in the foot is under the ball of the foot, between the 3rd and 4th toes, or between the 2nd and 3rd toes. Symptoms may include shooting pain, numbness, and/or burning sensations in the ball of the foot, which may radiate up the leg, or out to the toes. The pain occurs while standing or walking, and is aggravated by tight shoes, and stooping down on the toes. Often, the pain is relieved by removing the shoes and massaging the affected area. Some patients have likened the pain to a "vice grip" on the foot or a "hot poking iron" between the toes.
The cause of this problem is usually related to instability in the front of the foot, resulting in the nerve that course through the arch of the foot into the toes being compressed by the ligaments that hold the metatarsal heads together. It is this repetitive micro trauma to the nerve that causes it to become inflamed initially and eventually can lead to the nerve being chronically trapped in scar tissue as the body attempts to heal this trauma. It starts gradually, and can become quite debilitating, especially in those patient who are lifting and squatting, or on their feet all day during the course of daily work or activities.
Early diagnosis and treatment tend to provide better cure rates conservatively. Conservative treatment is initially aimed at decreasing inflammation in the nerve with the use of anti-inflammatories, and sometimes a cortisone injection. Custom made orthotic devices to be worn in shoes can help to control the forefoot instability as well. When initial treatment fails, often a round of physical therapy is needed along with a 2nd cortisone injection, and sometimes, if necessary, a new treatment: sclerosing injections.
Sclerosing agent injection therapy
A relatively new treatment for neuromas, .04% sclerosing injections are utilized to block innervation of the nerve at the diseased site. The patient undergoes injections once weekly for 6 to 7 weeks. This has a 70-80% success rate, and is one step used prior to surgical intervention, or if the patient is not a surgical candidate.
Endoscopic decompression of the intermetatarsal nerve has been developed to correct neuroma pain in a less traumatic manner, with a faster recovery time. This surgical technique involves three less than 5mm incisions on the foot, and the use of specially designed instrumentation to allow the surgeon to visualize the structures of the foot through a small camera on a video screen. In this technique, the ligament that is pushing on the nerve is released, thereby reducing the symptoms on neuroma pain. Patients generally can expect a return to tennis shoes 3 days after surgery, however every patient heals differently. This procedure is performed in an outpatient setting.
Excision of neuroma (surgical removal)
As a last resort, the neuroma can be removed surgically. This is a common procedure which is performed in an outpatient surgical center or hospital. Excision of the neuroma requires a bandage that must be worn for roughly 2 weeks, with the stitches being removed in 2 weeks time. Crutches are usually not necessary.
There are other conditions in the foot which mimic a neuroma, so a skilled podiatrist will rule these out upon physical examination. Stress fractures of the metatarsals and arthritis of the joints are two of the more common conditions to mimic a neuroma, so patients can expect X-rays to be taken during an initial visit.
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